Bending the Rules

Total knee replacement surgery can mean an end to pain and a new beginning for mobility

Jorge Ochoa could no longer really walk.Instead, all he could manage was to limp his way through day after agonizing day. Years before, the now-retired Port of New Orleans longshoreman had slipped on an oil slickened ship deck, and his subsequent surgery on both knees had left him without any buffering cartilage on either of the joints. Every movement, each step, meant jarring bone-on-bone pain. Ochoa finally had enough and opted for total knee replacement surgery, or total knee arthroplasty.

Today, Ochoa has little pain, and the 60 year old says the surgeries have changed his life.

"I can do things now that I couldn't do before."

More and more aging baby boomers like Ochoa are deciding it's too early to be relegated to the rocking chair or to be constantly afflicted by joint pain, especially when it comes to their knees. After exhausting other more conservative options, many are choosing to have worn out knees surgically replaced. A study presented at the 2006 Annual Meeting of the American Academy of Orthopaedic Surgeons, predicted the number of total knee replacement procedures performed in the United States annually would jump by 673 percent  to 3.48 million surgeries annually  by the year 2030.

These projections follow the recent national trend, which has seen the number of total knee replacements rise from 299,000 in 2000 to 478,000 in 2004, the most recent year for which statistics are available. There are a number of factors driving the increase, including the growing number of people with osteoarthritis, a disease associated with aging where joint cartilage degenerates until there is no cushioning between joints; the obesity epidemic (too much body weight places excessive stress on the hips and knee joints); and a population that wants to stay physically active, which is good for overall health but can place added demand on the joints.

Another reason more people are having total knee replacements has to do with quality of life. The surgery with an ensuing recovery time of about a year is very effective: it relieves the pain, increases the patient's range of motion and allows them to return to their daily activities, including sports. Plus, thanks to recent technological advances, minimally invasive surgical techniques and improved pain management, the procedure is more precise, safer and less painful.

Computer Assisted Orthopaedic Surgery (CAOS) allows a surgeon to map out the contours of a patient's knee during surgery and create three-dimensional models of it on a computer. By using the models and sensing equipment, which tells the surgeon exactly where to make incisions, the doctor can insert the knee prosthesis more precisely than with the standard technique.

According to Dr. Richard Meyer, an orthopedic surgeon at Touro Infirmary and the first local surgeon to use CAOS for total knee arthroplasty, the conventional method uses a rod drilled into bone to help the surgeon determine where to make his cuts. Meyer says that there is flexibility in the rod and that there is some guesswork involved.

"A lot of it is you're just eyeballing it," Meyer says. "This [CAOS] takes that fudge-factor out of it."

Meyer points to a 2004 study reported in the journal, Othopaedics (May 2004) that detailed the surgical outcomes of 100 patients who underwent total knee replacement surgery. Fifty of the patients had CAOS, and the other 50 were operated on using the standard technique. In 96 percent of the CAOS cases, the patients achieved "superior restoration of mechanical leg alignment" compared to 76 percent of patients who underwent the standard procedure.

Meyer began using CAOS about two years ago and has performed more than 300 total knee arthroplasties with computer assistance. Besides the added precision of CAOS, he says there is a safety factor as well. Because the rod is drilled into bone in the conventional surgery, there is an increase in the chances of a pulmonary embolism (blockage of a lung artery caused by blood clot), which can be fatal. With CAOS there is less drilling and less blood loss and, Meyer believes, a longer lasting prosthesis.

"All the studies show that if you have a knee in better alignment, that knee will have less wear, and, hopefully, less failure," he says.

In layman's terms, that means the prosthetic knee joint should last longer. Meyer says the average lifetime for a prosthetic knee is 10 to 20 years, but he believes that should improve with CAOS.

"With the newer technique the implants may last 20 years or longer," Meyer says.

That's good news for Denice Lessard, a 48-year-old New Orleanian, and the many like her who are getting knee implants at a relatively young age. On May 1, Meyer performed a total knee replacement on Lessard, who suffers from rheumatoid arthritis, the most debilitating form of arthritis in which joints become inflamed, painful and, eventually, deformed. Lessard was diagnosed with the disease in 1991 and has had 10 orthopedic surgeries to date.

She says she decided to undergo yet another surgery because she thought it would allow her "to be like I used to be." She hopes the total knee arthroplasty will be her last operation for a while. Even though it's only been two months since the surgery, she already has experienced some improvement.

"We were out a couple of weeks ago, and we saw some friends," Lessard says. "They said to me, 'God, your limp is so much better and you're walking so much better.'"

A total knee replacement is still an aggresive procedure and shouldn't be entered into lightly. Meyer stresses that other more conservative options should be explored before a total knee replacement is considered. Some of the nonsurgical treatments include knee bracing, which can aid with proper knee alignment and help balance the weight load on the joint; cortisone injections, which have been used to relieve the pain of arthritis by reducing inflammation of the joint; and physical therapy, which sometimes proves an effective alternative to surgery. In terms of surgery, options include arthroscopy, which is minimally invasive and can be used to remedy mechanical symptoms like joint locking; and osteotomy, which involves cutting and realigning the leg bone. Each has had demonstrated success in certain situations.

By the time patients become good candidates for total knee arthroplasty, they have exhausted all other options and are experiencing a high level of pain that is interfering with their daily lives. Dr. Robert Bostick, an orthopedic surgeon operating out of West Jefferson Medical Center says most of these patients already are familiar with the procedure, which is one reason he is performing more of the operations.

"It's a gradual climb," Bostick says. "People are getting more educated about this and are requesting it."

Bostick began using computer assistance in his total knee arthroplasties about eight months ago. The computer-assisted systems are expensive, he says, but he and his colleagues at Jefferson Orthopedic Clinic saw the potential and decided to buy a system and go through the training needed to use it.

"There's a lot of interest, and I do believe it's the wave of the future," Bostick says.

Locally, the number of total knee replacements hasn't risen at the same pace they have on a national level. Doctors at Ochsner's main campus in Metairie perform slightly less operations, around 300 per year, than they did earlier in the decade. At West Jefferson Medical Center, Bostick says the surgeons conduct about 100 total knee arthroplasties annually. The numbers have gone up at Touro Infirmary  increasing from 76 operations in 2003 to 130 in 2006.

Preparing for and forecasting a rise in total knee replacement operations and other joint surgeries is one reason why Touro recently opened its new Gulf South Joint Replacement Center. The center offers a variety of amenities to patients, including large, private hotel room-like accommodations with panoramic views of the city, comfortable chairs that can be converted into beds for "coaches" (family members or friends who encourage the patient in their post-operation recovery), plasma television sets and even monogrammed bathrobes.

The facility schedules groups of eight to 15 patients for a dedicated surgery day and then the group goes through in-hospital recovery together. After the two-hour operation, patients are brought back to their beds where they remain for the rest of the day. The next day, patients are bathed, dressed in their own clothes and sit up in chairs. After that, they participate in group physical therapy sessions in a public meeting room. Al Trevino, patient care manager in the center, says that by keeping the center's patients segregated in their own wing, staff focuses only on post-operative care and recovery.

"These patients aren't sick," Trevino says. "They're here because they have something wrong with their hip or knee and we're going to fix it."

Trevino adds that Gulf South Joint Replacement is one of only about 50 such centers across the country, and that the added luxuries shouldn't cost the patient anything extra in terms of health insurance.

"I don't think [insurance companies] care that we're providing these amenities, or whether or not [patients] are in a ward with four or five other people," Trevino says.

Even though Jorge Ochoa didn't get to enjoy the benefits of Touro's new facilities, he is very happy with the total knee arthroplasty that Dr. Meyer performed on him. It has been more than a year since his surgery  complete recovery takes about a year  and nowadays Ochoa is nothing short of a total knee replacement advocate. "When I tell my friends about that surgery, I say it's been a blessing."